Tuesday, 7 June 2011

Whether 'tis nobler in the mind to suffer the slings and arrows of outrageous fortune,

Or to take arms against a sea of troubles, and by opposing end them? – Shakespeare

A useful way to approach problems of anger, anxiety and depression is to see them not so much as separate issues, but as different kinds of response to ongoing frustration of the achievement of our goals, and to the sense of threat, stress and pressure that this brings. They are all potentially adaptive responses, as they are based on the evolved fight/flight/freeze system, but of course they can also be maladaptive.

Let’s think about them first from an emotional/behavioural point of view. We will look more closely further down at the cognitive themes which these feelings and behaviours would suggest.

Ongoing frustration of important goals, for instance failure to secure a job despite our best efforts, can first of all make us feel angry, but we don’t necessarily feel very fearful or demotivated yet. The anger we feel can give us energy for the fight, and determination not to be beaten. Of course it may also make us irritable and demanding, which may not help the situation.

Continued efforts without improvement may begin to frighten us – we start to sense that further fight may bring no change in our situation, and we may begin to feel threatened, to feel that our goals are really in danger. This can make us understandably very anxious, especially if these goals are fairly fundamental ones, such as making enough money to live, protecting our children, keeping ourselves healthy, hanging on to an important relationship etc. Again, these feelings can be adaptive, by helping us to be cautious and realistic, or they may just undermine our faith in our ability to cope, especially as we become more and more conscious of the fact that we are anxious. In the anxious state, however, we still feel some hope along with the doubt, feeling at least some of the time that it is worth while trying to re-engage with the struggle. We feel like running away, and may indeed do so some of the time, but we don’t give up completely.

If we lose this thread of hope, feeling that the struggle is no longer worth it, we find ourselves in the depressed state. This is the frozen, numb state, where caring about anything seems futile (as it seems like it cannot be achieved anyway), and any signs of hope, or even of success, are dismissed as illusory. We therefore don’t really try anymore, further reinforcing our lack of goal achievement. This is generally seen as a maladaptive state, and its possible adaptive function is less clear, but it may be

•An evolved mechanism of distress telling us to hibernate, escape or change something

•A signal that our coping system is overwhelmed and that we need time out

As I mentioned above, it is interesting to look at these three states from a cognitive perspective, as Beck does (e.g. Beck, A.T., 1976, Cognitive Therapy and the Emotional Disorders. New York: International Universities Press). The thinking described here may of course be realistic or unrealistic, functional or dysfunctional, to whatever degree.

Cognitively, the angry state reflects themes of perceived offense/transgression, rooting itself in the belief that something is wrong, unjust, unfair, and needs to be put right. Angry thinking and self-talk are characterised by phrases such as “should”, “ought”, “no right to”, “fault”, etc.

In the shift to the anxious state, we still see things as being wrong in some way, but we begin to see some aspect or aspects of the situation as more dangerous/threatening than we did, and our ability to cope with it as being less than we did. There is still a sense of defensiveness, but along with it a greater sense of vulnerability, and therefore our self-talk becomes less like fighting talk, and more safety-oriented: “what if?”, “I’d best not”, “I might fail” etc.

If the angry state is characterised by the view that some bad outcome shouldn’t happen, and the anxious state by the view that it looks as if it might happen despite our best efforts, then the depressed state sees it as having happened, actual loss rather than threatened loss, actual failure rather than possible failure. Furthermore, the depressed person can see no likely change to that situation, so their perspective is also one of futility; effort seems pointless, as there appears to be no real prospect of any significant action being rewarding.

Of course, there are ways out of this state, and they involve the reversal of the path we have just traced.

If efforts are to be made by the depressed person, especially in the important areas of life where they have experienced such disappointment and frustration, then these efforts need to be ones which lead to some feeling of reward (CBT therefore always starts with small, doable yet significant activities, such as getting a little bit of fresh air and exercise).

As a person begins to feel less depressed, and starts to look at their world again as maybe being a place of possibility rather than impossibility, the possibility of things going wrong again looms for them, and it is very common to move from depression back into anxiety. This is so uncomfortable that it can send many people back to depression again, so the therapist needs to make sure the client is ready for this, and help them shift the focus of the therapeutic work to the different themes of this state.

What is less obvious to many people is that if they are to re-engage with the life issues which were causing them so much stress, they may well need to revisit the angry state. This is normal, but it may need to be normalised for some clients. There may be dysfunctional expectations involved in their anger, and these may need to be worked on, along with learning more assertive ways of approaching life challenges. But there is also potentially useful energy in the angry state, and we may need to be reminded that anger is often a valid emotion if we are to step into the sea of troubles once again.